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Abstract

Introduction: Increasing access to contraception among women who enter the health system for HIV care is crucial to help them achieve their fertility intentions and reduce vertical transmission of HIV. Identifying intervention strategies that contribute to effective family planning/HIV service integration and synthesizing lessons for future integration programming and research is important to move the field forward.

Methods: Using a standard review methodology, we searched for articles in the peer-reviewed literature published between January 2008 and August 2013 that addressed the integration of family planning interventions into HIV service settings. Eligible studies were assessed in terms of methodological rigor; documented outcomes; and reported process and cost data.

Results: Twelve studies met our inclusion criteria. Eight studies documented significant increases in contraceptive use by HIV service clients, and three reported significant increases in completed referrals from HIV services to family planning clinics. The outcomes of the seven studies implemented in public sector facilities were more modest than the five studies embedded in clinical trials. Process evaluation measures for some of the studies indicated weak implementation of the intervention as intended. The average rigor score was low, 3.4 out of 9.

Conclusion: Our review reveals an expanding evidence base for integrated family planning/HIV service delivery innovations. However, the modest observed effect under typical settings and the evidence of weak intervention implementation emphasize the need for stronger programmatic efforts and implementation research to address the health system obstacles to integrating these two essential services.

Introduction

Increasing access to contraception among women and couples who are already in contact with the health system for their HIV care is crucial. It helps them achieve their fertility intentions and reduce vertical and horizontal transmission of HIV. Both the President's Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria increasingly recognize the value of family planning to programs they support [1–4]. In addition, UNAIDS deems prevention of unintended pregnancies among women living with HIV one of four key strategies essential for achieving the goals set forth in the Global Plan toward the Elimination of New Infections among Children by 2015 and Keeping Their Mothers Alive[5]. WHO's 2012 update of prevention of mother-to-child transmission (PMTCT) guidelines asserts, ‘family planning services still need to be strengthened to avoid unintended pregnancies [6].’

Despite these policy directives, health services are not providing HIV-positive women adequate support to achieve their pregnancy intentions [7]. A recent impact evaluation of the national PMTCT program in South Africa reported that perinatal transmission rates had dropped below 4% in the country – a major achievement – but close to two-thirds of the pregnancies among HIV-positive women in the study were unplanned [8]. Notably, the only statistically significant risk factor associated with mother-to-child transmission in the study was unplanned pregnancies. Studies from Côte d’Ivoire, India, Rwanda, South Africa, Swaziland, and Uganda also found high rates of unintended pregnancy among women living with HIV, ranging from 51 to 84% [9–15]. Others have reported low levels of contraceptive use among HIV-positive women who were not planning to have more children, indicating they are at high risk of unintended pregnancy [16–18]. In Uganda, 75% of HIV-positive women had unmet need for family planning, more than double the unmet need reported by HIV-uninfected women in the study (34%) [19].

Some studies have found contraceptive prevalence among HIV-positive women to exceed that of their HIV-negative counterparts or women in the general population, but most of the difference is attributed to self-reported condom use [20–24]. Although condoms offer the benefit of simultaneous protection from both pregnancy and transmission of HIV and other sexually transmitted infections, the pregnancy rates among typical users are substantially higher than those in users of other nonbarrier contraceptive methods [25]. Moreover, consistent condom use among HIV-positive women has been shown to be low [18,26]. Women with strong intention to avoid pregnancy should be encouraged to consider using a more highly effective contraceptive method, ideally in combination with condoms. Such dual method use maximizes protection from both unintended pregnancy and HIV transmission. However, a recent multicountry study found dual method use among HIV-positive clients not desiring pregnancy to be low: 36% in Namibia, 29% in Kenya, and 14% in Tanzania [27]. Approximately 53% of study participants reported using condoms only, a group described by the authors as having ‘reliable method unmet need.’ Even lower levels of dual method use among HIV-positive women have been reported elsewhere [13,22].

A systematic review of the evidence through 2007 for interventions linking family planning and HIV services found only four studies that reported contraceptive use as an outcome [28]. Just one of those studies documented an intervention that significantly increased contraceptive use among clients of HIV services; another showed an association between acceptance of HIV testing and use of contraception, including dual method use, among women presenting for postabortion care. This review also concluded that the evaluation rigor in the 16 included studies was low. Further, few studies reported data on the cost–effectiveness of integrating family planning and HIV services, and none were specifically designed to test the benefit of integrated services compared to vertical services. Ultimately, because of poor aggregate study quality, the review was unable to draw conclusions about optimal circumstances and best practices for family planning/HIV service integration.

In the interim, investigators have continued to examine approaches for integrating family planning and HIV services. We reviewed the recent literature to identify studies published since the last systematic review on this topic. We aimed to better define the outcomes of such integration efforts, identify intervention approaches that contribute to effective service integration, and synthesize lessons learned for future family planning/HIV integration programming and research.

Methods

Using a standard review methodology, we searched PubMed, Popline, PsycINFO, and CINAHL for articles published after 2007 (January 2008 to August 2013) addressing the integration of family planning interventions into HIV service delivery settings. Search terms used were family planning, contraception, HIV, PMTCT, integration, linkage, and evaluation. We also examined the bibliographies of articles identified in the database search for other relevant articles. For our review, family planning interventions included contraceptive counseling or education as well as provision of or referrals for contraceptive methods. HIV service delivery settings included HIV counseling and testing services, PMTCT services, and HIV care and treatment services.

All titles and abstracts identified in the database search were independently assessed by the lead author and a research assistant; these were narrowed to those that described evaluations of efforts to integrate a family planning intervention into HIV services. Any discrepancies were resolved by discussion. Full-text articles of abstracts that appeared to address the evaluation of a family planning intervention into an HIV service were obtained and examined. Ultimately, we included studies in our review if they met the following criteria: were published in a peer-reviewed journal between January 2008 and August 2013; presented postintervention evaluation data of an intervention integrating family planning into an HIV service delivery setting; and reported quantitative outcomes of interest identified a priori, including contraceptive uptake, family planning referrals completed, or pregnancy incidence. Unlike the earlier review of evidence for interventions linking any family planning and HIV services, we did not include articles examining linkages in the opposite direction (the integration of HIV services into family planning service settings). We assessed the studies in terms of the following:

To assess the methodological rigor of more recent studies, for consistency we used the same 9-point scale as in the earlier systematic review. This additive scale generates a score of 1 (low rigor) to 9 (high rigor) by assigning one point for each of nine criteria met. Studies received one point for each of the following criteria they met: pre/postintervention data; control or comparison group; cohort; comparison groups equivalent at baseline on sociodemographic characteristics; comparison groups equivalent at baseline on outcome measures; random assignment (group or individual) to the intervention; participants randomly selected for assessment; control for potential confounders; and follow-up rate greater than or equal to 75%. The studies included were independently assessed by two of the authors. Differences in interpretation were discussed, and consensus was reached on the rigor score assigned to each study. Other information was extracted from included studies by one of the authors and reviewed and confirmed by a second author.

Results

Our initial database search yielded 531 abstracts. After excluding review articles, the remaining articles were further narrowed to 34 original articles that addressed the integration of family planning and HIV services. Following full-text reviews of those articles, we identified 12 studies that met our criteria (Table 1) [29–40]. Two of these studies were randomized control trials [29,39], and eight were observational [30,32,33,35–38,40]. The remaining two relied on medical record data [31] and service statistics [34] to measure outcomes. Seven studies tested interventions that included the provision of contraceptive counseling and methods within HIV services [29,31–33,35,38,39]. Four of the studies evaluated intervention models in which HIV service clients desiring a family planning method were given a referral to the family planning clinic [30,34,36,40]. One study compared a referral-based model with one offering on-site method provision [37]. Seven of the studies were carried out with clients accessing voluntary counseling and testing (VCT), PMTCT, HIV care, or antiretroviral therapy (ART) services at public sector health facilities [30,31,33–36,40]; the other five were conducted at research sites with women and men accessing HIV services as part of their participation in a clinical trial [29,32,37–39]. All studies were conducted in sub-Saharan Africa.

All interventions were designed to increase access to contraception among clients of HIV services who did not wish to become pregnant. Although variation existed across the specific intervention approaches evaluated, they largely consisted of a package of activities that were clinic-based. All of the interventions included training of providers or counselors in the HIV clinic setting in provision of family planning counseling to clients. The four referral-based integration interventions included training of family planning providers [30,34,36,40]. Another common component across many of the interventions was the introduction of job aids or checklists to support contraceptive counseling to clients. Three of the studies reported modifying monitoring and evaluation forms as part of the intervention [30,34,40]. One intervention included a video-based educational component [29,39]. Only one study reported including nonclinic-based activities as part of the intervention [30]. In this study, advocacy meetings with local government stakeholders were part of the basic and enhanced interventions evaluated, and community mobilization was also part of the enhanced intervention. Some of the interventions were oriented toward couples, whereas others were intended for individual clients.

Study rigor

The average rigor score was 3.4 out of 9, with a range of 1–5. The most commonly noted methodological strengths were reporting of preintervention and postintervention data and following a cohort prospectively; all but two studies controlled for potential confounders [34,37]. By contrast, no study randomly selected participants for outcome measurement. Two studies randomly assigned participants to the intervention group, and these were the only studies to have at baseline intervention and control groups that were equivalent in terms of the outcome [29,39]. Only one study documented equivalent groups at baseline assessed in terms of sociodemographic characteristics [32], and four documented follow-up rates greater than 75% [30,35,37,38]. The studies varied widely in terms of the duration of time postintervention that contraceptive outcomes were measured, ranging from the same day the intervention was delivered to 18 months later.

Study outcomes

Contraceptive uptake was the most common family planning-related outcome reported. All but one of the 12 studies reported method-specific contraceptive use, allowing assessment of the effect of the intervention on use of methods other than condoms. Only three studies measured pregnancy incidence as an outcome [31,32,39]. With the exception of one study that measured family planning use 3 months following VCT [35], none examined contraceptive continuation.

Eight studies documented significant increases in contraceptive use by HIV service clients. In three of the studies, these increases were driven primarily by an increase in self-reported condom use [30,31,33]; another saw an increase in dual method use [40]. Three studies, two of which were implemented by the same research group, demonstrated a substantial increase in uptake of long-acting contraceptive methods among HIV-positive and serodiscordant couples [29,37,38]. Follow-up data from one of these studies also reported a decline in pregnancy incidence [39]. Another study reported successfully increasing dual method use among serodiscordant couples as well as reducing pregnancy incidence [32]. An evaluation of a large-scale family planning/HIV integration program using retrospective service data found family planning clinic attendance increased and contraceptive distribution rose following integration [34]. A study following a cohort of ART clients in Zambia reported that 62% of the women desiring a contraceptive method following the reproductive health counseling intervention successfully accessed family planning services within 90 days [36]. Two of the studies evaluating the integration of family planning services into VCT reported lower contraceptive method provision and uptake than expected; however, they both also noted that the client population had lower than expected unmet need for family planning [33,35].

Four of the studies were designed to allow for comparisons between groups exposed to the family planning/HIV integration intervention and control groups [29,31,32,39]. One of these, a randomized controlled trial conducted in Zambia with four study arms, found significant increases in contraceptive uptake across the four arms, all of which received couples contraceptive counseling and provision of a wide range of methods on-site and free of charge [29]. Participants exposed to an additional video-based component of the intervention focused on the intrauterine device and implants were more likely to choose a longer acting method. Over time, participants who were contraceptive users at baseline but switched to a longer acting method after viewing the video had lower pregnancy incidence [39]. The study in Thika, Kenya, which similarly offered couples contraceptive counseling and free, on-site provision of a range of methods to the intervention group, also reported substantial increases in noncondom contraceptive uptake and declines in pregnancy incidence [32]. Minimal change was observed in the comparison sites. The fourth study, which was a retrospective analysis of clinical data from Kenya, reported greater incidence of family planning use per 100 person years among the intervention group compared with the control group (58 vs. 45); the difference was primarily due to condom use [31]. New use of methods other than condoms was lower in the integration arm, and no difference in pregnancy incidence between the two groups was observed.

In addition to the four studies with a clear comparison group, a fifth study compared a ‘basic’ integration intervention to one that was ‘enhanced’ with training for family planning service providers, facility level support, and community mobilization [30]. Contraceptive use, primarily condoms, increased in both groups, but the enhanced intervention did not produce significant differential increases in contraceptive use. A sixth study compared a referral-based model of family planning integration with a model offering on-site provision of contraception in the HIV service setting [37]. Uptake of long-acting reversible contraception (implants) was significantly higher at the site offering on-site method provision (32% compared with 6% at the referral site).

Process evaluation

Six of the 12 studies included process evaluation data for assessing the extent to which the intervention was implemented as intended. In four of those studies, the process measure used was reports of the provision of contraceptive counseling by HIV service providers or counselors after the family planning integration intervention [30,33,35,36]. A fifth study used service ratios as a process measure [34]. The most extensive process evaluation data came from the ‘facilitated referrals’ study in Tanzania, which documented through client reports the extent to which all seven service delivery steps in the facilitated referrals model were implemented [40]. All of the studies measuring provision of contraceptive counseling reported increases in counseling after the intervention, though in some cases it was still lower than expected. For example, in the VCT intervention clinics in Ethiopia, nearly 60% of women and 70% of men did not receive contraceptive counseling after integration [33]. Similarly, only 17% of providers at the youth VCT clinics in Kenya reported always screening a female client for risk of unintended pregnancy [35]. That study also reported that only 33% of the providers interviewed had been trained in family planning/HIV integration, providing further evidence of low fidelity to the intervention.

In the study in Nigeria comparing basic and enhanced integration interventions, client reports of family planning counseling by ART providers increased in both groups postintervention; however, clients reporting receiving referrals to family planning services for noncondom methods remained low at follow-up: 26% of women in the basic group and 33% in the enhanced group [30]. The other referral-based intervention study in Nigeria reported service ratios relating completed referrals at family planning clinics to service utilization at the referring HIV clinics as a process measure [34]. Overall, service ratios were low, but increased after integration by four, 34, and 42 per 1000 clients from VCT, ART, and PMTCT clinics, respectively. The process evaluation data from the facilitated referrals study in Tanzania were more promising, with marked increases observed for several of the service delivery components of the integration intervention [40]. For example, client reports of a care and treatment provider discussing contraceptive methods with them increased from 56% preintervention to 75% postintervention, and reports of receiving a referral from the care and treatment provider increased from 7 to 47%. As was found in the earlier review, none of the 12 studies reported cost or cost–effectiveness data associated with the family planning/HIV integration intervention.

Discussion

Efforts to meet the family planning needs of people living with HIV have long been hampered by a lack of evidence-based service delivery strategies [41]. However, a body of evidence is emerging to help shape future integration priorities. Nearly all the studies included in our review produced encouraging results and important lessons to guide future research and programmatic efforts focused on reducing unintended pregnancies among women and couples living with HIV. Although overall study rigor was low, the studies showed that family planning/HIV service integration is effective in increasing contraceptive uptake among clients with HIV who do not wish to become pregnant. These findings largely reinforce the conclusions presented in the 2009 systematic review of studies examining integrated family planning/HIV services.

Most studies included in our review represent small-scale pilot investigations. With the exception of the Nigerian evaluation using data from 71 public health facilities, none evaluated a family planning/HIV integration program being implemented at scale. However, seven of the 12 studies were conducted in public sector clinics delivering HIV services in the context of common health system constraints, thus increasing understanding of the feasibility and effectiveness of the integrated services in ‘real world’ settings. Theoretically, service delivery interventions successfully implemented in such settings hold greater promise for being taken to scale than interventions tested under highly controlled conditions. That said, the impact of the family planning integration interventions in the public sector-based studies was lower than expected, particularly with respect to noncondom contraceptive uptake.

In contrast, the four studies with the most dramatic increases in noncondom contraceptive uptake were implemented in the context of clinical trials and are less generalizable to typical health system circumstances. Women who chose to participate in the study in Thika, Kenya were part of known serodiscordant couples and may not have been representative of the general population [32]. In addition, they initially agreed and were regularly counseled to avoid pregnancy so as not to affect their study participation. Outside a clinical trial setting, HIV programs with fewer resources would likely have less frequent contact with clients for follow-up care and may not be able to offer contraceptives free of charge. Nevertheless, the Thika study offers promising results related to increasing dual method use among HIV-positive women; furthermore, this is one of the few family planning/HIV integration studies to measure pregnancy incidence as an outcome.

The three studies that showed increases in uptake of long-acting reversible contraception are similarly unique in that the data are from women or couples who chose to enroll in research projects focused on HIV prevention [29,37,38]. Moreover, the randomized controlled trial in Zambia and the longitudinal cohort study in Rwanda and Zambia were conducted with a highly selected group of couples who opted for joint HIV testing [29,38]. Nevertheless, these studies suggest that on-site provision of long-acting methods is effective at increasing uptake among HIV-positive clients. Further, the studies generate evidence of effective program strategies to increase the use of longer acting and more effective contraceptive methods by HIV-positive and serodiscordant couples and postpartum PMTCT clients. Given the high reliance on condoms for pregnancy prevention by HIV-positive women, these studies make important contributions regarding ways to increase contraceptive method mix among HIV-positive clients. However, the feasibility of offering these methods free of charge in public sector facilities and outside the context of a clinical trial remains unexamined.

Six of the studies highlight potential for engaging men through family planning/HIV integration. The four studies targeting the intervention to couples were successful in increasing noncondom contraceptive uptake or decreasing pregnancy incidence [29,32,38,39]. In Nigeria, the proportion of men attending family planning clinics was significantly higher among clients referred from HIV clinics compared with nonreferred family planning clients [34]. In Ethiopia, increases in provision of contraceptive counseling and methods to men were similar to those reported for women [33]. These findings suggest that HIV services may be a promising platform for reaching men with family planning information and services. Given the influence male partners often have over decisions related to childbearing and contraceptive use, these opportunities warrant further investigation. Indeed, for women with HIV, disclosing their HIV status to their male partners and talking with them about the number of children they want has been associated with greater contraceptive use [13,42]. Moreover, the broader reproductive health literature has long endorsed constructive male engagement as central to effective family planning programming [43]. However, male engagement efforts should be undertaken with the intention of not only promoting acceptance and uptake of family planning, but also fostering greater gender equality and transformation of harmful gender norms that limit women's ability to achieve their reproductive intentions [44]. More research is needed to understand how men's attendance at HIV services can be leveraged to achieve better reproductive health and gender-related outcomes.

Despite prevention of unintended pregnancies among women with HIV being a core PMTCT program strategy, only two of the family planning interventions included in this review were introduced and evaluated in PMTCT clinics. This may be due, in part, to the challenges associated with delivering family planning interventions to traditional PMTCT clients. For example, PMTCT services typically begin in antenatal care (ANC) – after women are already pregnant [45]. As evidenced by reports of high rates of unintended pregnancies among PMTCT clients, many of these women need to be reached before they become pregnant. In addition, the postpartum impact of contraceptive counseling delivered in the antenatal period has been questioned [46]. After ANC, loss to follow-up occurs at each subsequent step in the PMTCT service cascade. In 2009, only 26% of pregnant women in 22 countries most affected by HIV/AIDS received HIV testing; among those pregnant women living with HIV, an estimated 53% received antiretroviral prophylaxis [47]. With only a small fraction of PMTCT clients returning to facilities for postnatal care, the impact of a family planning integration intervention in this setting has been limited. However, the expansion of Option B+ PMTCT services, whereby women identified during pregnancy as HIV-positive initiate lifelong ART, may create greater opportunity for the provision of postpartum services, including family planning. The two studies with PMTCT clients we reviewed suggest that targeting family planning interventions to these women – most of whom are in sexual unions, are of proven fertility, and are likely to be highly motivated to space or avoid future pregnancies – still warrants attention [34,37].

The findings from our analysis reveal an expanding evidence base for integrated family planning/HIV service delivery innovations. However, given the low rigor scores for most studies, the quality of evidence is relatively weak. While one future direction of effort could be investing in research designs that produce more precise findings about the effectiveness of integrated services, we believe the greatest opportunity for achieving public health impact lies in identifying solutions to practical service delivery challenges. Our results underscore the need to understand and resolve the health system obstacles to delivering integrated services and achieving better outcomes under typical service delivery conditions [48].

Systems factors at policy, infrastructure, and service delivery levels – such as lack of policy guidance on integrated care, staff turnover and shortages, poor oversight, ambiguous service delivery guidelines, and inadequate monitoring systems – have been identified as challenges to delivering integrated services [49,50]. The interventions included in our review consisted of complex, multipronged service delivery enhancements, many of which would be difficult to implement in the absence of a solid health system foundation. Indeed, the process evaluation data reported in several studies suggest that weak fidelity to the intervention may explain the lower than expected impact observed. As family planning/HIV integration is scaled up, increased attention must be focused on examining and strengthening fundamental health system components to allow service delivery interventions to be implemented with high fidelity and to achieve maximum impact [51].

Advances in understanding and resolving challenges rooted in health system constraints can be made through investments in implementation research, the discipline that applies multidisciplinary methods to arrive at solutions for increasing access to, use of, and public health impact of evidence-based interventions [52]. Specifically, as integrated services are scaled up, studies are needed to assess the process, cost, and outcomes of those services, and to identify the factors facilitating and impeding success in different contexts [53]. Implementation research studies would produce needed evidence regarding how to deliver high-quality, effective, and sustainable integrated services at scale under routine health service circumstances [54]. Such studies could also produce data on the costs of integration and the cost savings achieved through systematic service linkages.

Integrating family planning and HIV services holds promise as an effective strategy for increasing access to contraception among women with HIV who do not wish to become pregnant. Although our review suggests that many scientific and programmatic gaps related to family planning/HIV integration persist, we document that both the quantity and quality of the evidence base is evolving. Moreover, two notable, well designed integration trials funded by the Bill & Melinda Gates Foundation – the FACES trial in Kenya and the Integra Initiative in Kenya, Swaziland, and Malawi – recently ended. New findings from those studies are presented in this Supplement [55–57]. Efforts to translate the growing body of evidence supporting family planning/HIV integration into widespread practice, coupled with implementation research and broader health system reinforcements, have the potential to produce win-win gains on both reproductive health and HIV-related outcomes.

Acknowledgements

All authors contributed to conceptualizing the paper and reviewing and interpreting relevant studies. R.W. screened and identified articles to include from the peer-reviewed literature. T.H. and S.A. independently reviewed the studies and assigned rigor scores. R.W. and T.H. wrote the drafts of the paper, and S.A. and W.C. contributed to critical revisions. The authors would like to thank Tricia Petruney for her assistance in screening articles from the literature search for inclusion in our review.

Conflicts of interest

Support for this study was provided by FHI 360 with funds from the United States Agency for International Development (USAID), Cooperative Agreement Number GHO-A-00–09-00016-00, although the views expressed in this publication do not necessarily reflect those of FHI 360 or USAID.

12. Bangendanye L. Pregnancy, pregnancy desires and contraceptive use among HIV-infected women: findings from a survey of women enrolled in PMTCT in Rwanda. In: 3rd Annual Pediatric Conference on the Infected and Affected by HIV and AIDS. Kigali, Rwanda; 2007.

44. Ramirez-Ferrero E, Lusti-Narasimhan M. The role of men as partners and fathers in the prevention of mother-to-child transmission of HIV and in the promotion of sexual and reproductive health. Reprod Health Matters 2012; 20:103–109.

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